Okaloosa County BOCC — April 7, 2015 — NaCO Award CTP 2015 — reading text

National Association of Counties 2015 Achievement Award Nomination Summary: Okaloosa County EMS Comprehensive Quality Assurance and Training Program ABSTRACT In 2013, the Okaloosa County Emergency Medical Services facing a crisis of medical mistakes and their consequences on the patients they affected and the credibility of the organization. Responders in the County EMS system relied on online training to maintain competency and quality assurance was based on less than objective performance measures and competence criteria. The resulting decline in medical competency was having an impact on patients and the department by virtue of liability claims. This situation prompted the County EMS Chief and Medical Directors to develop the Okaloosa County EMS Comprehensive Quality Assurance and Training Program. Local fire chiefs and hospital administrative personnel also participated in the effort. The plan fostered participation between local fire departments, hospitals, and EMS in the development and implementation of new quality standards, pre- hospital medical performance measures, resource and data sharing procedures, and a comprehensive training program that provided realistic classroom and skills lab training modules based on local treatment protocols rather than commercially available web-based programs. The result was objective and measurable improvement in all categories of clinical competency and a higher quality of care system wide. THE PROBLEM OR NEED FOR THE PROGRAM In 2013, Okaloosa County Emergency Medical Services was facing a crisis of competency in its pre-hospital medical staff. Medical mistakes were being made at an unacceptable rate and the consequences for the patients and the credibility of the organization were equally unacceptable. The crisis evolved within the context of free falling property values, substantially reduced tax revenues, and ultimately much smaller training and continuing education budgets. The statutorily mandated minimum clinical standard for medical staff was achieved by subscribing to a virtual training system that allowed employees to watch videos and take tests online while on duty rather than participate in classroom and laboratory sessions with real hands-on experience. The few classroom courses that were offered were commercially formatted programs that lacked the necessary flexibility needed by instructors to make adjustments based on the learning needs of the individual or group. These courses were at best one-size- fits-all nationalized programs that failed in important ways to support local medical direction or improve the deeper pathophysiological understanding necessary for the development of highly competent EMS medical care. These circumstances lead to lower levels of clinical competency in the medical staff, bad Page |1 patient outcomes, and ultimately resulted in litigation against the County. The County had an obligation to provide the highest level of pre-hospital care possible with available resources, and as such, EMS leadership saw this situation as an imperative to action. DESCRIPTION OF THE PROGRAM From October to December 2013, in recognition of the growing competency problem, EMS leadership worked internally and with external stakeholders, primarily ALS fire departments and hospital administrators, to develop a comprehensive EMS Quality Assurance (QA) and Training Plan that included all medical responders in Okaloosa County operating under Okaloosa EMS Medical Direction. At its completion, the plan focused on establishing an organized process that outlines control measures intended to facilitate the delivery of the highest possible patient care to the citizens of the community. The plan also provided a comprehensive protocol for establishing clinical benchmarks, monitoring quality, reviewing patient care procedures and implementing plans for improvement. The primary objective and overall goal of the QA plan focused on the continual monitoring of patient care and delivery of immediate provider feedback from an established committee comprised of the EMS Chief, EMS Medical Directors, Shift Training Officers, Field Training Officers, Hospital staff, and ALS Fire Department Medical Officers. The QA plan was comprised of five key elements: Establishment of a Periodic Review and Maintenance of Clinical Core Measures (CCM): The QA committee convenes monthly to identify clinical core measures associated with each protocol section covered in the Comprehensive Training Plan. CCMs are tracked and monitored during the quality assurance chart and scene review process for the entire month. The data collected from the previous month’s review is presented on the date of the following QA Committee meeting and is used to develop future CTP training modules. Clinical deficiencies in patient care are identified this element of the program. Establishment of A Rolling 2-Year Comprehensive Training Plan (CTP) Based On Clinical Core Measures and Protocol Competency: The QA committee also meets monthly to determine clinical areas that have been identified as being deficient during the monthly chart/scene review process as described above. Once determined, a hands-on training module is developed that puts providers in the classroom and skills lab to further build on didactic concepts and practical skills. Deficiencies in patient care established during the periodic review are addressed in this element of the program. Daily Quality Assurance Monitoring: The plan establishes a process by which EMS Shift Training Officers and ALS Fire Medical Officers review and approve every patient care record (PCR) submitted in their respective departments daily. Deficiencies identified during this review process are documented on a standard performance Page |2 feedback worksheet and delivered to the employee for immediate feedback by the EMS Shift Training or Fire Medical Officer. The EMS Shift Training Officers also evaluate the on-scene performance of each employee a minimum of one call per month and complete the appropriate documentation and provide immediate employee feedback. Performance feedback worksheets marked as Immediate Formal Feedback Required are be presented to the EMS Medical Director for review at the monthly QA Committee meeting. The EMS Shift Training Officers and Fire Medical Officers are responsible for ensuring a daily comprehensive review of 100% of all Trauma Alerts, Cardiac Alerts, Stroke Alerts , cases involving advanced airway procedures (ETI, LMA, Cricothyrotomy…etc), cases involving air transport and cases involving the protocol of the previous month’s CTP. This is useful in identifying developing trends in care among specific categories of cases. Event-Based Case Reviews for Quality Assurance: In cases where a significant discrepancy in clinical judgment is identified and an Immediate Formal Feedback is Required, the QA Committee notifies the Medical Directors, conducts a 360 degree PCR review and identifies areas of deficiency and their causes (if possible). The committee also conducts a formal PCR review with the employee and makes recommendations to the Medical Directors for remediation. Monthly reporting of CCM: The EMS Shift Training Officers are responsible for submitting a comprehensive QA summary of all Core Competency Measures reviewed the previous month. In addition to CCM data, the report also contains the total number of charts reviewed, CCMs reviewed, any identified trends, and a comprehensive monthly summary, with suggestions for CTP modifications that will strengthen clinical performance. The Okaloosa County EMS Quality Assurance Plan was implemented on January 1, 2014. The plan and its supporting training and review programs were developed and tested over the three months of 2013’s fourth quarter. Course development continued throughout the first quarter of 2014 as review activities continuously produced new data on the clinical competencies of the providers in the field. The organization’s clinical competency baseline established through the daily and event-based reviews confirmed the anecdotal assumption that, as a whole, patient care was at and in some categories below standard. As well, these new processes confirmed that EMS leadership was correct in their sense of urgency to take action and take the lead on development and implementation of a plan to improve the quality of pre-hospital medical care in the county. The county played the lead role in this initiative. Okaloosa County EMS is the exclusive holder of the Certificate of Public Convenience and Need for Advanced Life Support Medical Care and Transport within the 950 square mile geographic boundary of Okaloosa County, Fl. As such, it is the sole ALS licensee of Florida’s Department of Health in the county. In 2003, EMS began entering into interlocal partnership agreements with municipal fire departments and local fire control districts to enhance EMS Page |3 care. The fire departments participating in the Advanced Life Support Fire Engine Partnership Program with EMS were allowed to provide ALS first response care under the EMS state ALS license. As a stipulation of the agreement, EMS and Fire operate under the same medical care protocols and take medical direction from the same medical director. As such, participating fire departments were direct stakeholders in the system-wide competency problem and were also compelled to contribute to the solution. EMS leadership and the Medical Director provided the venue for the early planning, program development, and testing phases. EMS leadership convened the first planning committee in September 2014 at the Okaloosa County Emergency Operations Center in Niceville, FL. All of the departments participating in the partnership agreement and area hospitals were represented. From then to the Thanksgiving Holidays, and under the direction of the EMS Chief and Medical Director, the group met every two weeks to identify problems, establish measurement criteria, develop data collection and analysis processes, and build and test training modules. The resulting product was a comprehensive quality assurance and training outline complete with objectives, processes, and desired outcomes. Over the month of December 2014, Okaloosa EMS fine tuned the outline and tested the training modules developed in the planning and development meetings. EMS conducted focus group-style testing sessions internally which included responders at the paramedic and EMT levels and with varying degrees of experience. Objective feedback from the participants was collected from the participants on the value of the material presented and its expected usefulness in the field. Reviews were mixed requiring some modules to be revised and updated. By January 1, 2014, the plan was finalized; a training schedule that included all departments on a rotating calendar, and an identified cadre of analysts and instructors was in place. Implementation began on schedule and the program has continued with remarkable success since. RESPONDING TO ECONOMIC DOWNTURN The problem this program was intended to address evolved due to the pressures of budget constraints on Okaloosa County EMS. As property valuations in the County fell during the recent recession, budget cuts were unavoidable. Training and quality programs in all departments presented as low hanging fruit as tough decisions were forced on managers at budget time. The years of do more with less-policies have ushered in a new economic reality for public and private organizations everywhere.